A recent opinion piece in BMJ careers argues that written reflection is ‘dead in the water’. I’d suggest you read it, but I personally disagree with most of it. I’ve tried to articulate my own counter-view in the five points below. What follows are my own beliefs, and I’d encourage you to leave a comment if (when?) you disagree.

​1 - Written reflection is not a choice…

The General Medical Council states that every doctor should regularly reflect on their own performance, professional values and their contribution to any teams in which they work. The FICM don’t specifically mention reflection as an expected behaviour in the syllabus, but there are several behaviours that it would be hard to demonstrate if reflection wasn’t part of your approach (and one of the five interview stations for ST3 ICM is a reflective practice station).

The NHS revalidation team is also hot on reflection being core to the appraisal process, explaining that it is the reflection on the supporting information rather than the information itself that informs the appraisal.

Whilst the need to write it down is not necessarily specified, It would seem that the author of the opinion piece needs to convince some pretty influential organisations of their view.

2 - You’d be hard pushed not to reflect…

Reflection is part of so called experiential learning, one of those educational concepts that is pretty obvious once it’s written down. The most well-known description of experiential learning is Kolb’s learning cycle, paraphrased below:

To my mind this is integral to being human, and I doubt you’d be able to survive without it. That’s not to say that we reflect and learn from every single experience, or that all learning comes from reflection (no-one reflects on reading the anatomy of the Brachial Plexus), but we certainly learn from many experiences, to do so requires a degree of reflection.

3 - Reflection is difficult….

To reflect on an experience is to challenge a belief. We may consciously choose not to do so (choosing to hold onto prejudices for example), struggle to come up with a new concept (finding difficulty making sense of the unexpected or idiosyncratic) or reject the experience as untrue (as a ‘freak’ exception). A requirement to reflect is a prompt to challenge ourselves and to develop as a result.

What makes this process even more difficult is to write it down, we can kid ourselves that the writing adds nothing. It’s easier when talking or thinking about an event however to bluff your way through, ignoring aspects of it, cutting corners and not coming up with any meaningful conclusions or challenges. The conclusions you may come up with can be difficult to articulate, but writing forces you to do so (writing this post, for example, seemed much simpler before I started it!).

Another feature that makes written reflection difficult is an extrinsic motivator i.e. doing it because we ‘have to’. Taking ownership and developing an understanding of the process might be the only way to avoid this, but to do so might require some ‘reflection on reflection’!

4 - Reflection has been misinterpreted for inappropriate means….

Reflection sometimes appears to be the solution to every problem, and it’s influence in the educational process is far reaching. It is a process that an individual undertakes, sometimes subconsciously, and not a process that can be done ‘to them’. When suggesting to an individual that they might want to reflect on an episode, the only possible favorable outcomes are that the individual records/verbalises an ongoing process of reflection, or that they are prompted to test whether an experience challenges their own beliefs and constructs. If it does not do either of these things, there can be no meaningful reflection; rather the ‘educator’ projects their own mental construct to the individual as an alternative which may or may not be accepted (a construct which may, of course, be completely wrong!).

The use of reflection after critical incidents etc. is rife, with the rationale that when something goes wrong we should do all we can to learn from it. Whilst there’s learning opportunities in pretty much everything, they do not all require a change in mental construct. For example, if a doctor gives the wrong dose of drug would reflection always be the right ‘remedy’? If the wrong dose was intentionally given, any reflection is merely a confession and a statement of facts would be more appropriate. If the doctor thought the dose was different (i.e. their belief was that they knew the dose and were giving the correct dose) then an educational intervention is appropriate. If the system is such that the doctor had been coerced into working a 72 hour shift, a root cause analysis would be the way forward (on the basis that the doctor believed that mistakes are more likely when tired and they still do).

​Written reflection as punishment or an indicator that ‘something has been done’ does nothing to encourage the process.

5 - Reflection shouldn’t lead to a life behind bars…

A position statement has been issued by the local HEE teams in London and the South East recently that caused a fair bit of angst. Essentially, it was based around a trainee (I have no details of this at all) releasing a reflective piece which was then apparently used to incriminate them. The statement says to focus on the learning from the event and to maintain confidentiality.​I’m no lawyer, but I would suggest there are several aspects to this:​

Confidentiality is a no-brainer, and even if the account doesn’t get you into bother, breaking confidentiality alone will. An article written by two medicolegal advisors suggests maintaining confidentiality so that the account can’t be linked to the case as evidence, but I don’t think that should be your motivation.

Access to reflective practice is said to have changed with the move to e-portfolios and online appraisal. I’m not convinced, in that surely it’s the existence of a document rather than where it’s stored that means a lawyer could ask for it?

The whole point of written reflection is to demonstrate a change in conceptual perspective. Unless therefore your pre-existing perspective was that you should deliberately or negligently do harm to a patient I can’t see the issue.

If the reflective piece does demonstrate ‘wrong-doing’ and the reflection is truthful, then the only issue with a lawyer getting hold of it is that more facts are available for a just outcome!

As I said at the beginning of this piece, please leave your own thoughts in the comments as these are only mine. Has reading this challenged your mental construct in any way?

(​Any Sunderland trainees not leaving a comment will be told to write a reflective piece on why that haven’t!)

On written reflection in general: I think we all agree as professionals that we ideally we will be looking to improve our practice whenever possible, and that this is the well intentioned motivation behind introducing compulsory written reflection. I propose that this is not the only method for improvement, in fact it is more documentation than a process in itself, and is heavily subject to the limitations of our own perception.

The other difficulty common to all written versions of mental processes, is that it is only a small sample. If we were to write down every incidence of learning and though process related to improvement that takes place even in a single day, we would all have written several holy books worth by now, so the written reflection that takes place is a highly filtered version of what is taking place, and in no way a comprehensive documentation of learning taking place, it is more of a sample to demonstrate that you are thinking about changing and improving.

There is a certain dogma that has built up around theories of learning, where we attempt to define what is taking place with an imperfect, but generally helpful model (kolb) and then try and impose that model on reality, stating that those that do not follow it exactly are not learning. The reality is that learning is much more fluid and complex than a four boxes, so any process designed to document evidence of learning needs to acknowledge this.

In most basic terms, we would all agree that if we are not looking at the true results of our actions (not just what we expect to be happening) with a defined goal in mind, then it is hard to know if we have done the best thing, and we are unlikely to be able to improve.

Learning involves, amongst other things; Learning what our goals should be in a given situation, learning what action needs to be taken to meet that goal, learning to do the action well, and obtaining accurate information on the true outcome, based on information from our own perception, and augmented with other perspectives. (the example of task fixation affecting our ability to monitor the result of our actions in the wider context and the need for third party perspective for accurate information).

There are other paradigms available for thinking about learning, and ericsson's 'deliberate practice' is helpful as a complimentary framework, but probably not the whole story either.

Written reflection needs to be recognised as a small contribution that demonstrates that we are analysing our performance with a view to improvement, and that we have a mindset that wishes to improve our practice. It cannot claim to be comprehensive documentation of all learning that has taken place.

In terms of what we should include in our written reflection - we need to be realistic that the document is actually fairly official an public, and write these pieces with the expectation that it will be read by many. The main intention of the written reflection is demonstrating that we are willing to review and look for ways to change our practice for the better.

The written reflection in the portfolio is not designed to be a place to document our darkest secrets, guilty confessions, or secret regrets.. (all humans have them!) this can be saved for a conversation with a trusted friend (and not written down!).

I think we will have to accept in our own minds that this will be a fairly selective set of points about and event, especially if it is about a sensitive care. (And that is not to say that you cant think about other issues as well - you can still action other improvement points, even if you havn't written them down in the formal reflection).

For the written reflections, the best approach will be to stick to facts, avoid wild speculation (and self incrimination), be mindful of hindsight bias (being unrealistic about what we could have done after the event) and come up with realistic positive suggestions about possible steps for the future.

It is hard though, when any less than perfect care is seen as unacceptable by some, and by suggesting the possibility of improvement, we are almost by definition admitting that care was less than perfect. Its a fine line to tread, and recent events highlight the need to think carefully about what we write for all to read, and what we keep as a personal reflection.